BOAST - Spinal Clearance in the Trauma Patient

Background and justification

All patients involved in significant blunt trauma must be assumed to have an unstable injury to their spine; the incidence is approximately 2% and increases up to 34% in the unconscious patient. 50% of spinal injuries occur in the thoracic or lumbar spine; 20% at two levels. Immobilisation with full spinal precautions for prolonged periods creates difficulties in intensive care units. Spinal immobilisation is associated with pressure sores and pulmonary complications and is not recommended for more than 48 hours. Audits in the UK suggest poor implementation of spinal clearance policies. In the neck ligamentous disruption without a major bony injury may lead to instability. Recent comparative evaluations have shown that a modern helical CT scanning with reformatting can demonstrate the subtle abnormalities offering high sensitivity and specificity in detecting unstable injuries of the cervical spine. Plain radiographs are insensitive in the neck and the upper thoracic spine. MRI scanning has high sensitivity but only moderate specificity and is logistically difficult for ICU patients.

Inclusions:

All trauma patients who are unconscious, unable to cooperate or who have distracting injuries that exclude reliable clinical assessment.

Exclusions:

Children under the age of 16

Standards for Practice

1. A protocol for protection of the entire spine must be in place in all hospitals managing trauma patients at risk ofspinal injury. This protection must be maintained from arrival until appropriate examination or investigations arecompleted and the spine cleared of injury.
2. Documentation of the neurological status must be made in all at-risk patients; any sign of spinal cord injurymandates urgent scanning.
3. A clinical examination of the whole spine should be documented.
4. If it is anticipated a patient will remain unconscious, unassessable or unreliable for clinical examination for morethan 48 hours, radiological spinal clearance imaging should be undertaken.
5. For the cervical spine, the appropriate standard is a thin slice (2-3mm) helical CT scan from the base of the skullto at least T1 with both sagittal and coronal reconstructions; extending that scan to T4/5 overcomes the difficultiesof imaging the upper thoracic spine.
6. It is recommended that this cervical spine CT scan be undertaken as a routine with the first CT brain scan in allheadinjured patients who have an altered level of consciousness.
7. The remaining thoracic and lumbar spine may be adequately imaged either by AP and lateral plain radiographs orby sagittal and coronal reformatting of helical CT scans of the chest, abdomen and pelvis undertaken as part of amodern CT trauma series (<5mm slices).
8. A senior radiologist must report spinal clearance images prior to withdrawal of spinal protection precautions.
9. If a spinal injury is detected, a neurological assessment must be made, even if incomplete, and repeated regularlyprior to urgent transfer to an appropriate spinal injury service.
10. MRI is the urgent investigation of choice for spinal cord injury.

Evidence base:

Predominantly retrospective case series but with good reviews and an evolved multinational professional consensus over 15 years.